Lets Build Our Health
15 min Free Phone Consultation
First Name
Last Name
Email
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What is your gender?
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Phone
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How old are you?
Check the conditions that apply to you or any member of your immediate relatives:
Arthritis
Diabetes
Hypertension
Cancer
Obesity
Kidney Disease
Other
Check the symptoms that you' re currently experiencing:
Pain
Dehydration
Weight Gain
Insomnia
Erectile Dysfunction
Musculoskeletal
Gastrointestinal
Cardiovascular
Chest Pain
Respiratory
Lymphatic
Hematological
Genitourinary
Neurological
Cardiac Disease
Other
Are you currently taking any medication?
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Did You Take the COVID Vaccine?
Please list any medications
Do you have any medication allergies? Please list If you do
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
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Where Are You Filling Out This Form?(Office, Online, Event Name)
Best Date and Time to call
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